Original Research

A comparative study of the clinical efficiency of

chemomechanical caries removal using Carisolv and
Papacarie A papain gel
J Kumar, M Nayak, KL Prasad, N Gupta
Department of Conservative
Dentistry and Endodontics, KVG
Dental College and Hospital,
Kurunjibagh Sullia (Karnataka),
India

ABSTRACT

Received
: 26-03-11
Review completed : 10-12-11
Accepted
: 08-02-12

Objectives: The purpose of this study was to compare the clinical efficiency of chemomechanical
caries removal using Carisolv and Papacarie - a papain gel.
Materials and Methods: The Carisolv system for caries removal, consisting of a solvent gel and
a specially designed hand instrument, was compared to Papacarie - a papain gel. The outcome
variables were: time taken for complete caries removal and volume of carious tissue excavated.
Forty patients in the age-group of 2040 years, having Blacks class I dentinal caries with cavity
entrance size of 3mm in the molars, were enrolled for the study. The time taken for the complete
removal of caries was measured using a stopwatch. Pre- and post-excavation single-step putty/wash
elastomeric impression was recorded using addition silicone impression material. Subsequently,
casts were poured and measured under a traveling microscope. The total volume of caries excavated
was computed using the formula (d/2)2h. The difference between the two groups in clinical
efficiency and volume excavated was statistically analyzed using the Students unpaired t test.
Results: The time for caries removal with Carisolv and Papacarie were, respectively,
11.673.25minutes and 10.48 2.96minutes (P>.05). The mean volume of carious tissue
removed with Papacarie (135.99 66.43mm3) was higher than that with Carisolv (126.33
53.56mm3); however, the difference was not significant.
Conclusion: Carisolv and Papacarie have similar clinically efficiency as chemomechanical
agents for dentinal caries removal.
Key words: Carisolv, chemomechanical caries removal, clinical efficiency, Papacarie - a
papain gel, traveling microscope

The word caries is derived from the Latin word for rot and
the Greek ker, which means death. Dental caries has been
known since times immemorial. According to the World
Health Organization (WHO) definition, caries is a localized
posterupted pathological process of external origin,
involving softening of hard tooth tissue and proceeding to
the formation of a cavity. It is one of the most prevalent
oral diseases and is of great public health concern. Caries
affects 50%60% of the Indian population.
Address for correspondence:
Dr Jitendra Kumar
E-mail: jeet_27dentist@yahoo.co.in
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DOI:
10.4103/0970-9290.107429

Carious dentine consists of two distinct layers having

different ultramicroscopic and chemical structures.
The outer layer of carious dentine (infected dentine)
is irreversibly denatured, infected by bacteria, not
remineralizable, and must be removed. The inner layer of
carious dentine (affected dentine) is reversibly denatured,
not infected, remineralizable, and should be preserved.[1]
Thus, the objective when treating the carious lesion is to
remove the infected layer, while retaining the affected
dentin.
Caries excavation has traditionally been performed using
rotary and sharp-edged hand instruments. These have
some major disadvantages; for example, there is difficulty
in establishing the amount of dentin to be removed due to
lack of objective clinical markers; mechanical preparation
often induces pain and discomfort; and there is generation
of heat, vibration, and noise. To overcome these drawbacks,
alternative methods have been proposed, including
chemomechanical techniques, air abrasion, sono-abrasion,
ultrasonic instrumentation, and lasers.[2]
Indian Journal of Dental Research, 23(5), 2012

Kumar, etal.

Chemomechanical caries removal

The chemomechanical caries removal method selectively

removes carious dentine but avoids the painful and
unnecessary removal of sound dentine. It facilitates delivery
of atraumatic, bactericidal and bacteriostatic activity, while
removing the least amount of tooth structure and not leaving
behind any infected and untreatable dentin.[3]
Carisolv gel (MediTeam, Sweden) was launched in 1998.
Its effectiveness is based on the proteolytic action of sodium
hypochlorite, which dissolves the infected dentin, and on
the action of amino acids, which enhance the effect of
sodium hypochlorite on denatured collagen and minimize
damage to healthy tissue.[4] In 2003, Papacarie gel (Frmula
and Ao, Brazil) was introduced as a biocompatible gel
with conservative, antibacterial, and atraumatic properties,
which could reduce the risk of pulp exposure and not
damage healthy tissue, making it an excellent option for
caries removal.[4]
Clinical efficiency or the time factor may be crucial for
acceptance of a treatment by some patients, especially
children and medically compromised patients. The
volume of tissue removed offers evidence of the minimal
intervention effect of the chemomechanical method of
removing carious tissue.
The purpose of this study was to compare the clinical
efficiency of chemomechanical caries removal using two
agents: Carisolv and Papacarie.

MATERIALS AND METHODS

Forty patients with Blacks class I occlusal dentinal caries in
permanent molars, with dimensions of 3mm (maximum
entrance size), brownish-gray discoloration, and soft
consistency, were selected for the study [Figures1 and
2]. Preoperative intraoral periapical radiograph was taken
with a Confident dental xray unit set at 70 kV and 7 mA,
using Kodak E-speed x-ray film and the bisecting angle
technique so as to exclude any pulpal involvement and
periapical lesion associated with an asymptomatic chronic
carious lesion.
The scientific committee approved the study, clearance
was obtained from the ethical committee, and written
informed consent was obtained from all participants. The
40 patients were randomly divided into two groups (group
I and group II) of 20 patients each. Group I patients were
treated with Carisolv gel and group II patients were treated
with Papacarie.

Initial impression making

The stock plastic sectional tray was selected and a polyvinyl

siloxane tray adhesive (Dentsply) was applied in a thin and
even layer over the intaglio surface of the tray. All materials
were mixed manually in the standard proportions according
Indian Journal of Dental Research, 23(5), 2012

to the manufacturers recommendations. Impression making

was done with the putty/wash single-step impression
technique, using elastomeric addition silicone (Dentsply)
[Figures3 and 4]. The cast was poured on the obtained
impression using type IV die stone (Pearl stone, Asian
Chemicals, India) to measure maximum entrance size
(3mm) and initial volume of the cavity using a traveling
microscope.

Procedure for caries excavation

Group I - Carisolv gel
The target carious tooth was isolated with rubber dam.
Solution I and solution II of Carisolv gel were mixed
and applied into the cavity. Timing of the procedure
started at initial application of gel and was recorded using
a stopwatch. After 30 seconds, the cavity was gently
scraped using a Multistar excavator (Mediteam, Sweden)
to remove the softened carious tissue. Only light pressure
was used on the instrument, without causing any pain to
the patient.[5]
At application, the fresh gel was clear but it became opaque/
cloudy with admixture of debris removed from the lesion.
When the gel was heavily contaminated with debris it was
removed with gentle suction or with a cotton roll/pellet,
and fresh gel was applied.[5]
The completeness of dentinal caries removal was judged on
the basis of clinical criteria, i.e., the explorer does not stick
in the dentin or give a tug-back sensation and the cavity
is stain free [Figures5 and 6]. If carious dentin remained,
then the procedure was repeated until the whole caries was
removed. Finally the cavity was rinsed with water, dried,
and examined; if found to be caries free, the timing of the
procedure was stopped.[6]
Group II - Papacarie- papain gel
The same procedure was followed as in group I, except that
the motion of the instrument which was pendulum like. As
with Carisolv gel, the freshly applied Papacarie gel was
clear. Immediately after degradation, oxygen was freed,
bubbles appeared on the surface, and there was blurring
of the gel.[4]

Evaluation of time taken for complete caries

removal

The stopwatch was started when the application of Carisolv

or Papacarie gel was begun and stopped only when the
cavity was confirmed to be stain free, without any tug-back
sensation or binding of the explorer.

Final impression making

The final impression was made after the completion of

caries excavation in a similar manner as was done for initial
impression making [Figures7 and 8]. Immediately cast was
poured to study under traveling microscope.

Chemomechanical caries removal

Figure1: Photograph showing Blacks class I cavity in relation to 36

for group 1

Kumar, etal.

Figure2: Photograph showing Blacks class I cavity in relation to 37

for group 2.

Figure3: Elastomeric impression before caries excavation (group 1)

Figure4: Elastomeric impression before caries excavation (group 2)

Figure5: Caries excavation after application of Carisolv (group 1)

Figure6: Caries excavation after application of Papacarie (group 2)

Figure7: Elastomeric impression after caries excavation (group 1)

Figure8: Elastomeric impression after caries excavation (group 2)

Indian Journal of Dental Research, 23(5), 2012

Kumar, etal.

Chemomechanical caries removal

Graph 1: Comparison between volume excavated in group I (Carisolv)

and group II (Papacarie)

Measurement of the volume of carious tissue

removed

The difference between final and initial sizes of the cavity

was measured using a traveling microscope. The linear
measurement of the cavity entrance size was measured to
the nearest 0.5mm and the average value for the cavity size
was estimated. The final cavity size (in cubic millimeters)
was computed using the formula p (d/2)2h.[7]
The differences between the groups in clinical efficiency
and volume excavated was compared and statistically
analyzed using Students unpaired t test. Correlation
between volume excavated and time taken in each
group was analyzed by calculating the coefficient of
correlation.

RESULTS
The patients in this study were aged 2040 years, with a
mean of 27.3 years in group I and 27.5 in group II. Twentythree patients (57.5%) were males and 17 (42.5%) were
females. Twenty-one (52.5%) teeth were in the lower arch
and 19 (47.5%) in the upper arch [Table1].

Clinical efficiency/time taken

Graph 2: Scatter diagram showing the correlation between volume

of caries removed and time taken in group I (Carisolv) and group II
(Papacarie)

CORRELATION BETWEEN VOLUME OF CARIES

EXCAVATED AND TIME TAKEN
A strong correlation was observed between the volume
of caries excavated and the time taken for both group II
(Papacarie) (r = 0.766) and group I (Carisolv) (r =0.683)
[Table4]. In both the treatment groups, the greater
the volume of caries removed, the more the time taken
[Graph2].

DISCUSSION
The best way to ensure maximum life for the natural tooth
is to respect the sound tissue and protect it from damage
by using minimally-invasive techniques in restorative
dentistry. With respect to collagen degradation, two zones
can usually be distinguished within a lesion, as demonstrated
by Ogushi and Fusayama in 1975: an inner layer in which
collagen is intact (affected dentin) and a second zone where
the collagen fibrils are partially degraded and cannot be
remineralized (the infected dentin).[8]

VOLUME OF CARIES EXCAVATED

Invitro studies have shown chemomechanically treated

dentin to have more surface energy, greater affinity for
adhesive material, and better bonding than conventionally
treated dentin. Moreover, morphological studies have
shown Carisolv treatment to consistently remove the
carious lesion and open the dentinal tubules along with
more irregular and rougher surface with modified smear
layer.[9]

The mean and standard deviation of the estimated volume

of carious tissue removed from the cavities in each
technique is shown in Table3. The volume of carious
tissue removed was less in group I (Carisolv) (126.33
53.56mm3). However, the difference was not statistically
significant (P>.05) as shown in Graph 1.

Ansari etal.[3] advocated the chemomechanical caries

removal method over the conventional method due to
the advantages offered by the former, which include less
traumatic caries removal, less need for local anesthesia, high
patient preference, reduced chance of exposure in deep
carious cavities, great usefulness in immunocompromised

The mean time for complete caries removal in group I

(Carisolv) was 11.67 3.25minutes, whereas the mean
time in group II (Papacarie) was 10.48 2.96minutes.
The difference was statistically nonsignificant [P>.05;
Table2].

Indian Journal of Dental Research, 23(5), 2012

Kumar, etal.

Chemomechanical caries removal

Table 1: Description of mean age, distribution of teeth, and genderin group I (Carisolv) and group II (Papacarie)
n

Groups
Group I (Carisolv)
Group II (Papacarie)

Mean age of patients (years)

20
20

27.3
27.5

Table 2: Comparison of clinical efficiency/ time taken

(minutes) in group I (Carisolv) and group II (Papacarie)
using students unpaired t test
Groups
Group I (Carisolv)

n
20

Mean
11.6785

Std. deviation
2.96687

Group II (Papacarie)

20

10.4845

3.25210

t
1.21300

Table 3: Comparison of volume of caries excavated (mm3) in

group I (Carisolv) and group II (Papacarie) using students
unpaired t test
Groups
Group I (Carisolv)
Group II (Papacarie)

n
20
20

Mean
126.3305
135.9961

Std. deviation
53.56283
66.43296

t
0.50700

Table 4: Correlation between volume of caries excavated

(mm3) and time taken (minutes) in group I (Carisolv) and
group II (Papacarie)
Group I (Carisolv) Time taken (min: sec) vs volume excavated
(mm3)
Coefficient of correlation (r)
0.683
Significance (P)
<.001
Number of patients (n)
20
Group II (Papacarie) Time taken (min: sec) vs volume excavated
(mm3)
Coefficient of correlation (r)
0.766
Significance (P)
<.001
Number of patients (n)
20

patients and patients with bleeding disorders, absence of

a smear layer, and better bonding to restorative materials.
The initial size of the carious lesion was selected as 3mm
in this study because lesions with dimensions 2mm
would not have provided sufficient access for the CMCR
instrument to reach the dentinal caries.[10] Invivo studies
have shown the Carisolv instrument to be less painful
than the traditional rotary instruments or excavators.[11]
Although the Papacarie manufacturer recommends the
use of old, blunt curettes, we opted to use the instrument
supplied with the Carisolv kit in order to obtain
standardization.
Margakis etal.[6] estimated the dimensions of removed
carious tissue with the aid of a calibrated dental probe,
assuming that all carious material was rectangular in shape.
They acquired an estimate of the total volume removed by
multiplying the linear dimensions of the occlusogingival,
mesiodistal, and faciolingual lengths. Lennon etal.[12] used
silicone impression material for calculation of volume. The
impression was weighed and cavity volume was calculated
according to the density of the impression material. LozanoChourio etal.[7] in 2006 used metallic structured calipers

Arch
Max.
8
11

Mand.
12
9

Males
11
12

Gender
Females
9
8

to measure cavity entrance size before and after removal

of caries and estimated volume of tissue removed by using
the formula (d/2)2h. In this study, the volume of caries
excavated was calculated by first making a single-step putty/
wash impression, followed by analysis of the cast under a
traveling microscope and calculation of volume using the
formula (d/2)2h. This method has several advantages: the
greater accuracy of the single-step putty wash impression
material, the availability of study casts as a records, and the
accuracy of the traveling microscope (accurate up to 1/100th
of a millimeter).
In present study, it was noticed that the actual dimensions
of the cavity was larger than was apparent clinically on
the occlusal surface. Hence, to record all the details of the
cavity, including undercuts, addition silicone impression
material was used. Johnson and Craig[13] showed addition
silicone to demonstrate the best recovery from undercuts,
extremely high accuracy, superior tear resistance, less
polymerization shrinkage, increased dimensional stability,
and neutral odor and taste; besides, it permits multiple
accurate casts. Polyvinyl siloxane material shows 96.86%
overall accuracy.[14]
Hung etal . reported that the putty/wash one-step
impression technique did not differ substantially in
dimensional accuracy from the putty/wash two-step
impression technique when addition silicones were used.[15]
Similarly, Abuasi and Wassell[16] concluded that the most
convenient and reliable way of recording a putty-wash
impression is to use the one-stage technique with addition
silicone putty. The present study employed the single-step
putty/wash impression technique using addition silicone
impression material to record the cavity dimensions prior
to and after chemomechanical caries excavation.
In the present study, dyes were not used because dyes
are not specific for infected dentin; they are nonspecific
protein dyes that stain the organic matrix of less mineralized
dentin, including normal circumpulpal dentin and sound
dentin in the area of the amelodentinal junction. The lack
of specificity of caries-detector dyes was confirmed in 1994
by Yip and others.[17] The caries excavation in the present
study was judged to be complete by using clinical criteria,
i.e., tactile and visual examination. However, this method
is subjective and has shortcomings.
The mean time taken for complete caries removal
in the present study with group I (Carisolv ) was
11.673.25minutes, whereas in group II (Papacarie) it
Indian Journal of Dental Research, 23(5), 2012

Kumar, etal.

Chemomechanical caries removal

was 10.48 2.96minutes. Our results were in accordance

with that of two separate studies conducted by Hosein and
Hasan[18] and Ansari etal.[3] who recorded 12.5minutes
and 1012minutes, respectively, for caries removal
using Carisolv. Balciuniene and Ericson also recorded
10.5minutes and 10.4minutes for chemomechanical
caries removal using Carisolv in comparison to high-speed
excavation. Faster excavation using chemomechanical
method were observed by Habib etal., Fure etal., and
Maragakis etal .[6], who recorded 68minutes, 5.9
1minutes, and 6.0minutes, respectively.[11] Motta etal.[4]
found that the time required for the treatment using
Papacarie was about 6minutes. Pandit etal.[19] recorded
45minutes for the traditional method and 8minutes
with Carisolv. The reason for the increased time in group
I (Carisolv) in the present study may be because we used
multiple applications of Carisolv gel to achieve complete
caries removal.

alpha-1 antitrypsin; its proteolytic action in inhibited in

healthy tissue, which contains alpha-1 antitrypsin.[4]

In this study, all cavities were found to be clinically

caries free after being treated with Carisolv (group I) and
Papacarie (group II), which is concordant with the results
reported by Ericson etal., Banerjee, Kidd and Watson, and
Fure etal. who showed that Carisolv was as effective as
rotary bur in removing infected carious dentin.[5] However,
Hosoya etal.[9] reported incomplete caries removal in 63.6%
of their cases, and Maragakis etal.[6] reported residual
caries in 37.5% of their cases after treatment. Balciuniene
etal.[11] reported the need of the bur in 60% of their cases
for achieving complete removal of caries. Munshi etal.[20]
described the CMCR method as very efficient in soft caries
removal, but reported that it was not very effective in 90%
of cases with hard, arrested dentinal caries.

An important limitation of the technique evaluated in

this study is that hand instruments are not appropriate
for cutting enamel and, nowadays, most cavities are not
large enough to allow proper access to carious dentin. This
limitation might make the public feel misled and might
raise doubts as to whether this is really a satisfactory
solution for the very unpleasant conventional treatment
of dental decay.

The results of the present investigation show that

Carisolv and Papacarie are both clinically efficient as
chemomechanical agents for caries removal. However,
Papacarie gel was marginally better in the parameters used
to measure clinical efficiency.

CONCLUSION

The active ingredient in Carisolv, sodium hypochlorite,

combines with amino acids to generate chloramines. This
results in chlorination of partially degraded collagen and
the conversion of hydroxyproline to pyrrole-2-carboxylic
acid, which initiates the disruption of collagen fibers and
softening of the outer layer of carious dentin. Beeley etal.[21]
suggested that cleavage by oxidation of glycine residue could
also be involved. This causes disruption of collagen fibrils,
which become friable and are then easily removable.
Papacarie is constituted of papain, chloramines, and toluidine
blue. Papain is an enzyme similar to human pepsin, with
anti-inflammatory and debriding actions. It does not damage
healthy tissue, but accelerates the cicatricial process and has
bacteriostatic and bactericidal action. Papain acts only on
carious tissue, which lacks the plasma protease inhibitor
Indian Journal of Dental Research, 23(5), 2012

In the present study, strong correlation was observed

between time required for complete removal of caries
and volume of caries excavated. Time taken was directly
proportional to volume of caries excavated. This has a
clinical significance because the larger the cavity size the
more the time required for complete caries excavation.
It was interesting to note that all patients in both groups
experienced no pain at all even though they did not receive
any anesthetic. This may be due to fact that Carisolv
instruments are specially designed for a safe scraping action,
having a 90 edge and not a sharp cutting profile. This design
allows the operator to work in two or more directions and
reduces breaking off of dentin and the opening up of a large
number of dentin tubules.[11]

Further research with large sample size and longer followup is required to substantiate the findings of this study.
Also, color and hardness were used as clinical criteria to
indicate endpoint of excavation, but these may not always
be reliable.

Within the limitations of this study comparing the clinical

efficiency of chemomechanical caries removal using
Carisolv and Papacarie, the following conclusions could
be drawn:
Carisolv and Papacarie were both clinically efficient
for carious dentin removal.
Papacarie was marginally better in the tested clinical
parameters, i.e., time taken and volume of carious tissue
excavated.

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How to cite this article: Kumar J, Nayak M, Prasad KL, Gupta N. A
comparative study of the clinical efficiency of chemomechanical caries removal
using Carisolv and Papacarie - A papain gel. Indian J Dent Res 2012;23:697.
Source of Support: Nil, Conflict of Interest: None declared.

Indian Journal of Dental Research, 23(5), 2012

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